The four hour A&E target: an accident waiting to happen?

The four hour accident and emergency waiting target was introduced following significant pressure on the government. The media, consumer groups and professional organisations were disgusted at what they described as the “scandal” of high numbers of vulnerable patients being left for many hours, sometimes overnight, on trolleys in A&E departments across the country. 

Services should be clinically led and supported by management, not the other way around

A large number of acute hospitals have made significant progress in achieving the 98 per cent standard and managing to sustain it despite winter pressures. It could be argued that since the introduction of the target, patients attending A&E are more effectively tracked and have greater access to diagnostics and senior medical review within four hours. 

Many see this as evidence of the target’s success. However, debate over the last few years has led some organisations, for example the RCN Congress 2008, to express concern over the potential for some unintentional consequences, such as potential patient safety incidents.

Rising demand

There have been a number of anecdotal claims that the four hour target has put more pressure on A&E by increasing demand from patients, who assume they are guaranteed to see a doctor within four hours and so choose not to book an appointment with their GP. While there does appear to have been some growth in A&E demand, it is difficult to prove the relationship between this and the four hour target.

Increases in binge drinking, domestic violence and knife crime have also put additional pressure on A&E, while increasing patient choice means that when it comes to accessing unscheduled care many simply choose to go the nearest place that is open out of hours.

Competing priorities

The Maidstone and Tunbridge Wells Healthcare Commission report and the more recent Mid Staffordshire Healthcare Commission report demonstrate some common themes. They highlight that organisations are faced with competing priorities. In some cases, this could divert their attention from important issues such as patient safety, infection control and quality in order to achieve key access targets and financial balance.

However, while some clinical staff may feel targets are distorting clinical priorities it would be hard to find anyone who would want their loved one left on a trolley in A&E for longer than four hours, for their operation to be cancelled or for them to be put at risk from infection.

The solution is that we have to achieve both quality and access targets and they need to be viewed as co-dependant rather than competing priorities. Elevated quality and financial control need to be seen as consequences of effective patient flow and access - not as competitors. The medical condition of the patient should be paramount in determining the conditions of their treatment, and should not influenced by a desire to meet a target.

This is not a job just for managers - clinicians need to use their expertise to find solutions to achieve the targets while ensuring that this is pursued as a vehicle to improve safety and quality.  Services should be clinically led and supported by management, not the other way around.